Medicaid Non-Emergency Medical Transportation: Overview and Key Issues in Medicaid Expansion Waivers

Issue Brief
  1. Transit Cooperative Research Program, Impact of the Affordable Care Act on Non-Emergency Medical Transportation: Assessment for Transit Agencies at 2 (Oct. 2014), http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_rrd_109.pdf.

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  2. 42 C.F.R. § 431.53.

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  3. 42 U.S.C. § 1396a(a)(4)(A).

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  4. 42 C.F.R. § 441.62; see also 42 U.S.C. § 1396a(a)(43) (requiring state to arrange for screening services and corrective treatment for EPSDT beneficiaries).

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  5. 42 C.F.R. § 431.53.

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  6. See, e.g., J. Kim et al., “Transportation Brokerage Services and Medicaid Beneficiaries’ Access to Care,” 44 Health Serv. Res. 145-161 (2009), http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2669622/; see also Centers for Medicare and Medicaid Services., EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children and Adolescents (2014), http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/Downloads/EPSDT_Coverage_Guide.pdf.

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  7. Kaiser Family Foundation State Health Facts, Federal Medical Assistance Percentage (FMAP) for Medicaid and Multiplier Data Source: FY 2017: 80 Fed. Reg. 73779 (Nov. 25, 2015), https://www.kff.org/medicaid/state-indicator/federal-matching-rate-and-multiplier/.

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  8. 42 U.S.C. § 1396a(a)(70); 42 C.F.R. § 440.170(a)(4).

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  9. S. Rosenbaum, et al., Medicaid’s Medical Transportation Assurance: Origins, Evolution, Current Trends, and Implications for Health Reform (July 2009), http://hsrc.himmelfarb.gwu.edu/cgi/viewcontent.cgi?article=1035&context=sphhs_policy_briefs.

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  10. P. Hughes-Cromwick and R. Wallace, et al., Cost-Benefit Analysis of Providing Non-Emergency Medical Transportation, Transit Cooperative Research Program (Oct. 2005), http://onlinepubs.trb.org/onlinepubs/tcrp/tcrp_webdoc_29.pdf.

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  11. Id.

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  12. Richard Wallace, et al, “Access to Health Care and Nonemergency Medical Transportation: Two Missing Links,” 1924 Transportation Research Record: Journal of the Transportation Research Board 76-84 (2005), http://www.researchgate.net/publication/39967547_
    Access_to_Health_Care_and_Nonemergency_Medical_Transportation_Two_Missing_Links
    .

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  13. Id.

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  14. The Stephen Group, Volume II: Recommendations to the Arkansas Health Reform Task Force (Oct. 2015), http://www.arkleg.state.ar.us/assembly/2015/Meeting%20Attachments/836/
    I14099/TSG%20Volume%20II%20Recommendations.pdf
    .

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  15. LogistiCare Solutions, Medicaid Gross Trips by Treatment Type (Nov. 2015) (on file with authors).

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  16. Id.

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  17. LogistiCare Solutions, NJ Expansion Analysis (on file with authors); LogistiCare Solutions, NV Expansion Analysis (on file with authors).

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  18. Id.

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  19. S. Borders, Transportation Barriers to Health Care: Assessing the Texas Medicaid Program, Dissertation submitted to Texas A&M University Office of Graduate Studies (May 2006), http://oaktrust.library.tamu.edu/bitstream/handle/1969.1/6016/etd-tamu-2006A-URSC-Borders.pdf?sequence=1&isAllowed=y.

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  20. 42 C.F.R. § 440.390. The Affordable Care Act requires states to expand Medicaid to adults with income up to 138% FPL as of 2014. However, the Supreme Court’s decision on the constitutionality of this provision effectively made expansion a state option. See Kaiser Commission on Medicaid and the Uninsured, A Guide to the Supreme Court’s Decision on the Medicaid Expansion (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2012), https://www.kff.org/health-reform/issue-brief/a-guide-to-the-supreme-courts-decision/. Expansion adults receive an alternative benefit plan. 42 U.S.C. § 1396(k)(1).

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  21. Kaiser Commission on Medicaid and the Uninsured, Financing Medicaid Coverage Under Health Reform: What is in the Law and the New FMAP Rules (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, May 2013), https://www.kff.org/health-reform/issue-brief/financing-medicaid-coverage-under-health-reform-the-role-of-the-federal-government-and-states/.

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  22. Kaiser Commission on Medicaid and the Uninsured, The ACA and Medicaid Expansion Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Nov. 2015), https://www.kff.org/medicaid/issue-brief/the-aca-and-medicaid-expansion-waivers/ . To date, 32 states (including DC) have implemented the ACA’s Medicaid expansion, most of which have done so through a traditional state plan amendment instead of a waiver. Kaiser Family Foundation State Health Facts, Status of State Action on the Medicaid Expansion Decision Data Source: Based on KCMU tracking and analysis of state executive activity (Jan. 12, 2016), https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/.

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  23. Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Pennsylvania: Transition from Waiver to Traditional Coverage (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-pennsylvania/.

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  24. Arizona expanded Medicaid in 2014 as envisioned in the ACA but is now seeking changes through waiver authority as required by state law. Kaiser Commission on Medicaid and the Uninsured, Proposed Changes to Medicaid Expansion in Arizona (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Nov. 2015), https://www.kff.org/medicaid/fact-sheet/proposed-changes-to-medicaid-expansion-in-arizona/.

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  25. Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Tennessee (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Jan. 2015), https://www.kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in-tennessee/; Kaiser Commission on Medicaid and the Uninsured, Proposed Medicaid Expansion in Utah (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Jan. 2015), https://www.kff.org/medicaid/fact-sheet/proposed-medicaid-expansion-in-utah/.

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  26. Kaiser Commission on Medicaid and the Uninsured, The ACA and Medicaid Expansion Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Nov. 2015), https://www.kff.org/medicaid/issue-brief/the-aca-and-medicaid-expansion-waivers/.

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  27. Kaiser Commission on Medicaid and the Uninsured, A Look at the Private Option in Arkansas, (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Aug. 2015), https://www.kff.org/medicaid/issue-brief/a-look-at-the-private-option-in-arkansas/; Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Arkansas (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015),  https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-arkansas/.

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  28. The Stephen Group, Volume II: Recommendations to the Arkansas Health Reform Task Force (Oct. 2015), http://www.arkleg.state.ar.us/assembly/
    2015/Meeting%20Attachments/836/I14099/TSG%20Volume%20II%20Recommendations.pdf
    .

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  29. GAO did not ask states to provide their reasons for not seeking to exclude NEMT from expansion adults, but 14 states offered reasons.  Eight reported considering NEMT critical to ensuring access to care, four reported wanting to align new adult and traditional Medicaid benefit packages, and two reported seeing no need to alter the benefit as expansion did not significantly increase program enrollment.  U.S. Gov’t Accountability Office, Report to Congressional Requesters, Medicaid, Efforts to Exclude Nonemergency Transportation Not Widespread, but Raise Issues for Expanded Coverage,GAO-16-221 at 10 (Jan. 2016), http://www.gao.gov/products/GAO-16-221.

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  30. Three states (AZ, IA, and IN) indicated that they were pursuing efforts to exclude NEMT for expansion adults.  Two states (NJ and OH) did not respond to GAO, but CMS confirmed that neither had sought to exclude NEMT as part of their Medicaid expansions.  Id. at 6.

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  31. Id.at GAO Highlights page.   

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  32. Kaiser Commission on Medicaid and the Uninsured, The ACA and Medicaid Expansion Waivers (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Nov. 2015), https://www.kff.org/medicaid/issue-brief/the-aca-and-medicaid-expansion-waivers/ ; Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Iowa (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Nov. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-iowa/; Kaiser Commission on Medicaid and the Uninsured, Medicaid Expansion in Indiana (Washington, DC: Kaiser Commission on Medicaid and the Uninsured, Feb. 2015), https://www.kff.org/medicaid/fact-sheet/medicaid-expansion-in-indiana/.

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  33. Letter from Cindy Mann, Director, CMCS, CMS to Julie Lovelady, Interim Medicaid Director, State of Iowa (Dec. 30, 2014), http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ia/ia-marketplace-choice-plan-ca.pdf.

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  34. Id. 

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  35. Letter from Vicki Wachino, Director, CMCS, CMS to Mikki Stier, Medicaid Director, State of Iowa (July 31, 2015), http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ia/ia-marketplace-choice-plan-ca.pdf.

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  36. CMS Special Terms and Conditions, Iowa Wellness Plan, Section VII. 41 (p. 14) (Jan. 1, 2014-Dec. 31, 2016, amended July 31, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/ia/ia-wellness-plan-ca.pdf.

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  37. Letter from Eliot Fishman, Director, CMS to Joseph Moser, Medicaid Director, Indiana Family and Social Services Administration (Dec. 22, 2015), https://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Waivers/1115/downloads/in/Healthy-Indiana-Plan-2/in-healthy-indiana-plan-support-20-response-ltr-12222015.pdf.

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  38. GAO at 15.

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  39. Id. 

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  40. Id.at 15, n.32.

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  41. Id. at 15.

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